Management of B12 deficiency and the Covid-19 pandemic – By Dr Tracey Eastbrook
The Covid Pandemic has caused NHS England to review all of its face to face patient contacts to minimise risk of harm to both patients and NHS staff.
All face to face interaction has been carefully reviewed to balance the benefits versus the risks. Factored into this consideration is the additional time required for such interactions.
Extra time is needed for application and removing of personal protective equipment (PPE), cleaning of equipment such as BP cuffs, chairs and examination couches.
As we move forward out of lockdown it is becoming increasingly apparent that we need to find a way to provide care in the safest way whilst we all live and work alongside this virus.
The core provision of care by general practice in managing both chronic diseases and urgent/minor illness needs to resume in a safe way.
GP practices have already revolutionised the way they provide care. They have needed to embrace new technology to facilitate video consulting, texting photos and managing a significant proportion of problems by telephone. All of these result in less face to face contact reducing footfall in to the surgery.
Management of Vitamin B12 deficiency is one area where guidance has changed considerably. Vitamin B12 is used in metabolism by blood and nerve cells. It is absorbed by the gut from the food we eat.
Deficiency can be divided into two broad groups. The most common cause is dietary. Vitamin B12 is naturally found in animal products including fish, meat, poultry and dairy products such as milk, yoghurt and cheese. Low animal diets therefore increase the risk of dietary deficiency. This is Dietary Vitamin B12 Deficiency.
Some people can eat a diet rich in B12 but can still be deficient. This is called Non-Dietary Vitamin B12 Deficiency. The most well-known of these causes is Pernicious Anaemia. Patients with this condition produce an antibody that prevents absorption of B12 from the gut.
Other causes of non-dietary B12 deficiency are malabsorption conditions such as Inflammatory Bowel Disease, Achlorhydria and Short Bowel Syndrome where the ability to absorb B12 will be reduced but not completely prevented.
Traditionally both of these groups have been treated in the same way, by an intramuscular injection every 3 months. However the necessity of such an approach has been questioned during this pandemic.
We know that the body is very clever at storing vitamins, minerals and micronutrients that can be called upon when the body needs them. This makes sense to me as we have evolved as human beings from hunter-gatherers; living through times of feast and fast. Iron is stored in our body as Ferritin, providing a ready source of iron to produce new red blood cells when required, as they renew every 120 days. When we run out of Ferritin we become anaemic.
The fat soluble vitamins A, D, E and K are stored in our body’s fat stores and B12 is stored in the liver. Evidence suggests that these stores of B12 last at least a year.
In view of this the British Haematological Society (BHS) has created a Covid-19 guideline for patients in both groups to be treated with oral tablets. This high dose regimen will maximise absorption opportunities in the gut and keep stores topped up. It is recognised that those unable or with reduced absorption capability will be relying on their stored B12 reserves.
GP Practices are now therefore providing Vitamin B12 tablet prescriptions to those who usually receive injections. Patients can feel reassured that if they have had regular injections pre-Covid then they will have their liver stores.
At Balmoral whilst we await further guidance from the BHS, we will be making efforts to categorize patients into their B12 deficiency groups and provide opportunistic injections to those in the non-dietary B12 category.
Opportunistic is defined as being given if a patient contact is required for another essential reason, such as drug monitoring or illness. In the future dietary B12 deficiency is likely to be treated with oral tablets and twice yearly injections but we await guidance.
Severe B12 deficiency affects blood and nerve cells causing anaemia and neurological symptoms usually in the legs. Anyone that received pre-covid regular B12 injections who experiences fatigue, leg weakness, numbness or unsteadiness should consult a GP.